School of Geoscience

University of Edinburgh

School of GeoScience

Personal Details and Declaration Form

Course No. and Title:
To participate in a departmental field trip you must complete and sign the following health declaration form.
In the majority of cases the information provided by you in this, your “Health Declaration”, will be sufficient, when reviewed by Course Leader / School H&S Department to pass you as medically suitable for your field trip. Some students however may be required to discuss information contained in their Health Declaration in further detail with a Doctor or travel health adviser and may subsequently require a medical examination.
Additionally you may need to arrange an appointment for your travel advice and any recommended vaccinations if required.
Please note any medical details supplied will remain confidential to Course Leader / School H&S Department and no information will be provided to others without your informed consent.
PERSONAL DETAILS
Surname: / First Name:
Home Address:
Tel No: / Date of Birth:
Matric No.
Passport No*. / European Health Card* / Yes / No
* Only applicable if going abroad.
NEXT OF KIN DETAILS (PERSON TO BE CONTACTED IN CASE OF EMERGENCY)
1. Principal Contact: / Name: / Relationship to you:
Address:
Tel (Day): / Tel (Evening): / *Give full dialling codes
2. Second Contact: / Name: / Relationship to you:
Address:
Tel (Day): / Tel (Evening): / *Give full dialling codes
Please list any special circumstances which affect your capability to undertake any of the work of the excursion on any day. Failure to do so may invalidate the insurance and may result in you paying medical / travel costs.
Please list any allergies / special dietary requirements you may.

Declaration:

I certify that my answers to the questions are complete, accurate and no information has been withheld. I understand that if this is later shown not to be the case it may result reconsideration of my suitability to travel. If between now and my due date of departing, my medical circumstances should change, I undertake to seek medical advice regarding my suitability to travel.

I undertake to inform the Trip Leader as soon as possible of any change in my medical circumstances between the date signed and the beginning of my Field Trip/Study /Work Abroad.

Signed:______Date: ______

Full Name:______

(Capitals)

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